Implementation Date: 7/28/17
Developmental Disabilities (DDD) regulations and Medicaid Home and Community-Based Services (HCBS) Waiver
guidelines:
Nebraska Administrative Code Title 404 Regulations, 4-008.01, Section 5d: An aggregate report of incidents must be submitted to the Department on a quarterly basis. Each report must be received by the Department no later than 30 days after the last day of the previous quarter. The reports must include a compilation, analysis, and interpretation of data, and include evidentiary examples to evaluate performance that result in a reduction in the number of incidents over time.
HCBS Waivers Appendix A, Section 7, b.i. (A.7.b.i.) and Appendix G-Quality Improvement: Health and Welfare, Section b.i. (G.b.i.): Quarterly, providers submit a report to DHHS-DD detailing the incidents in the quarter and actions taken both on a participant and provider wide level to address the issue and to decrease the likelihood of future incidents.
All agency providers are expected to complete reports consistently, as outlined in the schedule and directions
below, to demonstrate their compliance with state and federal regulations by improving the services they
provide.
1st Quarter January – March April 30th
2nd Quarter April – June July 30th
3rd Quarter July – September October 30th
4th Quarter October – December January 30th
1. Log into the Therap Nebraska Page found here: https://help.therapservices.net/app/nebraska 2. Open the Quarterly Report template in Therap from the Incident Reporting Module towards the bottom of
the page. 3. Within the template, enter the provider name (Within the space provided and the footer), the reporting
quarter, and the start/end dates of the quarter. Complete a Save As so new information can be added. 4. Select Agency Reports from the Dashboard page. 5. Go to the Report Library. Select View. 6. Type GER into the Report Name, then press the Search Tab. 7. Click on GER Report-Management Summary 8. In the Event Start date section, enter the first day of the Quarterly Reporting Period. 9. In the Event End Date, select the last date of the Quarterly Reporting Period. 10. Export to Excel 11. Select Enable Editing 12. Save the Excel report to your folder. NOTE: Go to Step *20 if you choose to develop the graphs manually. This
manual step will need to be taken for Mac users. Go to Step 23b if there were no high notification GERs for the quarter.
13. NOTE: Prior to completing steps 13-17 to run a Macro to auto-populate the graphs, you must first adjust your trust settings in Excel by clicking the File tab, then selecting Options, Trust Center, Trust Center Settings, Macro Settings, then if allowed by our agency, select Disable all macros with notification and click OK.
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14. This setting will allow you to be notified each time the Macro Report is viewed, so you can confirm the report is a trusted source.
15. In Therap, open the spreadsheet titled “Provider Report Macro”. 16. Enable Content to open the folder and select Yes to trust the Macros.
17. From the Home Tab of the Excel Ribbon of the Therap data report you ran in steps 7-12, Click on the View tab.
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18. Click on the Macros tab and select View Macros. NOTE: For earlier versions of Excel you will complete these steps from the Developer Tab by Clicking Options from the File tab. Select Customize Ribbon in the left pane, and then click the Developer check box under Main Tabs on the right side of the dialog box. Click OK.
19. Select Macro Data 2.xls Provider report and click on the Run tab. 20. The quarterly incident data will auto-populate the graphs.
NOTE: Instead of running the Macros, you may also create your own pivot graphs. From the Insert Tab, Separately, insert Pivot Charts (Sheets 1-3) and a Pivot Table (Sheet 4) into your data Spreadsheet:
Sheet 1/Pivot Chart 1***: Sheet 2/Pivot Chart 2***:
Sheet 4 Sheets 1-3
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Sheet3 /Pivot Chart 3***: Sheet4 /PIVOT TABLE 1***:
**After clicking and dragging the information from the Pivot fields, Status is filtered to exclude deleted events, Notification level is filtered to include only High notification events. Count of Forms is Form ID.
21. Copy and Paste the graphs from sheets 1-3 into the Provider Report template. The graph from sheet 4 will not be pasted into the report, but can be used as you analyze the data.
22. In Section 1, Data Compilation, review the data graphs. 23. In Section 2, labeled Provider and Participant Data Analysis and Action Plans to address Incident Reduction or
Systemic Patterns, please type or write requested information for each shaded blank section of the incident categories requiring analysis. (The tab button should be used when going to each blank section.) To enhance your analysis, you can right click on any digit within the Excel report (see first screen-shot below) to view all data for the chosen area to analyze if there are any trends or systemic patterns.
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a. After clicking on the incident entry number for the quarter within the spreadsheet, separately, review the
Program/Site, Individual Last Name, Individual First name, Event Date, Other Summary, What happened Before Incident, Event Day and Event Time columns to analyze if any trends or systemic patterns exist.
b. NOTE: Alphabetical sections B-U needing no analysis, as described in the table for the event category,
should be deleted and removed from your Provider Report. Systemic issues may include: 1. A single incident caused by employee actions or inactions, 2. or repeated incidents impacted by procedures, limitations, or protocols.
Category boxes can be deleted, see screenshot below, by placing your cursor in the box, right clicking on the small square appearing to the left upper corner of the box, then delete the table.
24. Areas asking for analysis within Section 2 will include:
a.
Analysis:
conditions are present:
A participant had three or more incidents.
This quarter’s total exceeded the prior provider or participant
total.
Check and describe reason(s) for additional analysis. Examples of possible reasons include, but are not limited to:
The number of incidents increased from the prior quarter.
The participant had (team-defined) number of incidents this quarter.
There was a provider-wide problem causing an increase. List the specific nature or type of incidents.
b.
Action Plan to address Incident Reduction or Systemic patterns:
Explain, in detail, action plans that will be taken or have already been taken to address incidents for the participant or provider, or list why additional action plans should not be implemented to address the analysis of the incidents: .
List action plans that will be taken or have already been taken to address incidents or systemic patterns for the participant or provider. Possible examples may include:
The team met for one participant and decided to revise his bus schedule times.
The program will increase training and on-site assistance for staff this quarter.
Increased on-site assistance and training for staff during incidents to increase the autonomy of the staff and improve their ability to manage maladaptive behaviors at the initial stage to prevent full participant escalation.
Every employee will receive a refresher Behavioral Intervention course, which teaches nonviolent crisis prevention.
This section may also include the reason(s) why additional actions to address the incident category should not be implemented to address the incidents. Possible reasons include, but are not limited to:
A participant left the provider’s service.
Actions are not necessary because the number of incidents decreased significantly this quarter.
No systemic trends were noted with the incidents. A. High Notification GER Overview: Complete the template by filling in the shaded sections with the
requested information.
This quarter there were high notification level General Event Reports (GERs), which
included high level incidents and participants. In comparison, there were ___
High Notification GERs the prior quarter.
B. – U:
Complete these sections by documenting information within the 2nd column based on the
conditions listed within the first column.
Example 1:
conditions are present:
This quarter’s total exceeded the prior provider or
participant total.
more incidents.
Example 2:
conditions are present:
There were systemic issues.
completed this quarter.
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V. Enter the number of participants with more than 4 high GERs.
Include an additional analysis and action plan addressing events improperly categorized as High
notification events based on the GER Instruction Guide Reportable Incident List.
Analysis:
Action Plan to address Incident Reduction or Systemic patterns:
Explain, in detail, action plans that will be taken or already taken to address incidents for the
participant or provider, or list why additional action plans should not be implemented to address
the analysis of the incidents:
.
W. Include any trends noted for the participants. Trends may include events occurring within multiple high
notification GER categories or patterns over-lapping GER incident categories.
W. There were participants with more than 4 high GERs.
Analysis:
Action Plan to address Incident Reduction or Systemic patterns:
Explain, in detail, action plans that will be taken or already taken to address incidents for the
participant or provider, or list why additional action plans should not be implemented to address
the analysis of the incidents:
: .
c. In Section 3, labeled Data Interpretation, complete the information as listed within the template. Fill in the shaded sections to complete your analysis:
a) The overall incident Increase/Decrease is possibly due to
b) Additional actions to address the overall incident increase are/are not needed because
c) Reporting of incidents to the participant, family member/legal representative (As
appropriate), the Service Coordinator, CPS/APS and Law Enforcement as appropriate was
completed properly and timely for of GER incidents.
d) GERs were approved properly and timely for of GER incidents.
e) Notification levels for GERs were initially completed properly for
of GERs.
f) GERs were submitted within required timelines for of GER
incidents.
g) Corrective actions were taken for of GER incidents.
Action Plan to address Incident Reduction or Systemic patterns:
Explain, in detail, action plans that will be taken or have already been taken to address incidents
for the participant or provider, or list why additional action plans should not be implemented to
address the analysis of the incidents: .
d. Sign or list the name(s) and title(s) of those completing the report. e. When finished, send a Word version to:
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Therap via SCOMM to: First name: DHHSDDQuality Last name: Mailbox
Quarter: Quarter Data: Quarterly Report Due Date:
1st Quarter January – March April 30th
2nd Quarter April – June July 30th
3rd Quarter July – September October 30th
4th Quarter October - December January 30th